A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?

The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.

Choice A rationale:

Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.

Choice B rationale:

Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.

Choice C rationale:

Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.

Choice D rationale:

Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.

Choice A rationale:

Tachycardia, or a rapid heart rate, is not typically an adverse effect of oxygen therapy. Oxygen therapy is often used to help people with conditions like COPD, COVID-19, emphysema, and sleep apnea get enough oxygen to function and stay well. While tachycardia can be a symptom of these conditions, it is not directly caused by the oxygen therapy itself.

Choice B rationale:

Cracks in the oral mucous membranes can indeed be an adverse effect of oxygen therapy. Oxygen therapy involves the delivery of highly concentrated oxygen, which can cause irritation and dryness in the airways, including the oral mucous membranes. This can lead to cracks and discomfort in the mouth. Therefore, it’s important for healthcare providers to monitor patients receiving oxygen therapy for signs of this adverse effect.

Excessive pulmonary secretions are not typically a direct adverse effect of oxygen therapy. While conditions that often require oxygen therapy, such as pneumonia and COPD, can lead to increased pulmonary secretions, these are symptoms of the underlying disease rather than the oxygen therapy itself.

Choice D rationale:

Poor skin turgor is not typically an adverse effect of oxygen therapy. Skin turgor refers to the elasticity of the skin, and poor skin turgor is often a sign of dehydration. While oxygen therapy can cause dryness of the mucous membranes, it does not typically affect the hydration status of the skin.